The impact of the COVID-19 pandemic on Sexually Transmitted Infections surveillance data: incidence drop or artefact?

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Sentís et al. BMC Public Health   (2021) 21:1637
https://doi.org/10.1186/s12889-021-11630-x

 RESEARCH ARTICLE                                                                                                                                    Open Access

The impact of the COVID-19 pandemic on
Sexually Transmitted Infections surveillance
data: incidence drop or artefact?
Alexis Sentís1,2,3,4†, Albert Prats-Uribe5†, Evelin López-Corbeto1,2, Marcos Montoro-Fernandez1,
Daniel Kwakye Nomah1,6, Patrícia Garcia de Olalla2,7, Lilas Mercuriali7, Núria Borrell8, Víctor Guadalupe-Fernández9,
Juliana Reyes-Urueña1,2*, Jordi Casabona1,2,6 and Catalan HIV and STI Surveillance Group

  Abstract
  Background: Before the COVID-19 pandemic, Sexually transmitted infections (STIs) were increasing in Europe, and
  Spain and Catalonia were not an exception. Catalonia has been one of the regions with the highest number of
  COVID-19 confirmed cases in Spain. The objective of this study was to estimate the magnitude of the decline, due
  to the COVID-19 pandemic, in the number of STI confirmed cases in Catalonia during the lockdown and de-
  escalation phases.
  Methods: Interrupted time series analysis was performed to estimate the magnitude of decline in the number of
  STI reported confirmed cases - chlamydia, gonorrhoea, syphilis, and lymphogranuloma venereum- in Catalonia since
  lockdown with historical data, from March 13th to August 1st 2020, comparing the observed with the expected
  values.
  Results: We found that since the start of COVID-19 pandemic the number of STI reported cases was 51% less than
  expected, reaching an average of 56% during lockdown (50% and 45% during de-escalation and new normality)
  with a maximum decrease of 72% for chlamydia and minimum of 22% for syphilis. Our results indicate that fewer
  STIs were reported in females, people living in more deprived areas, people with no previous STI episodes during
  the last three years, and in the HIV negative.
  Conclusions: The STI notification sharp decline was maintained almost five months after lockdown started, well
  into the new normality. This fact can hardly be explained without significant underdiagnosis and underreporting.
  There is an urgent need to strengthen STI/HIV diagnostic programs and services, as well as surveillance, as the
  pandemic could be concealing the real size of the already described re-emergence of STIs in most of the European
  countries.
  Keywords: Public health, Surveillance, communicable diseases, Sexually transmitted infections, Interrupted time
  series, COVID-19, Lockdown, Trends, Epidemiology

* Correspondence: jmreyes@iconcologia.net
†
 Alexis Sentís and Albert Prats-Uribe contributed equally to this work.
1
 Centre of epidemiological studies on sexually transmitted infections and
AIDS of Catalonia (CEEISCAT). Department of Health. Generalitat of Catalonia,
Badalona, Spain
2
 Spanish Consortium for Research on Epidemiology and Public Health
(CIBERESP), Instituto de Salud Carlos III, Madrid, Spain
Full list of author information is available at the end of the article

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Sentís et al. BMC Public Health   (2021) 21:1637                                                               Page 2 of 7

Background                                                   are used for case definition criteria and all reported cases
Before the coronavirus disease 2019 (COVID-19) pan-          are reviewed by epidemiologists from the Epidemio-
demic, the number of new cases of mandatory notifiable       logical Surveillance Network of Catalonia (XVEC) to
sexually transmitted infections (STIs) was increasing in     ensure completeness and validity of the data.
many European countries. Catalonia also had a pro-
nounced rise of chlamydia, gonorrhoea, syphilis and          Study variables
lymphogranuloma venereum (LGV). For the last five            Sex, age group, and country of birth were collected from
years, Catalonia presented the highest incidence rates of    REC. Deprivation index (calculated by the Agency of
Spain in all mandatory notifiable STIs, with a 20% an-       Health Quality and Assessment of Catalonia) was based
nual increase. The rates were highest among males who        on the patient area of residence and categorized in quin-
have sex with males (MSM) and young adults, mostly fe-       tiles, with the first quintile being the least deprived [9].
males aged between 20 to 24 [1]. STIs represent one of       Multiple episodes by the same STI in the same individ-
the highest burdens of disease in adolescents and young      ual were considered reinfections when evidence of it,
females, leading to miscarriage, pelvic inflammatory dis-    proper treatment, and minimum length of time between
ease, and increased risk to acquire human immunodefi-        reports existed. Time periods were defined according to
ciency virus (HIV) [2–4]. According to data published        specific STI treatment duration and follow up recom-
by the Government of Catalonia, the COVID-19 pan-            mendations, being 364, 29, 119 and 119 days respectively
demic hit Catalonia harshly, with 676.863 confirmed          for syphilis, gonorrhoea, chlamydia and LGV [10]. HIV
cases and 22.124 deaths by May 24th, 2021, with one of       status was confirmed checking the HIV status among in-
the highest number of confirmed cases in Spain [5, 6].       dividuals who had one single or more STI episodes dur-
On March 13, the Spanish government announced a              ing the study period within the Catalan HIV/STI
countrywide lockdown, with a mandatory stay at home          Registry of Catalonia where previous and simultaneous
ordinance, with some exceptions, such as purchasing          HIV coinfections can be identified.
food or medicine, going to work or attending to emer-
gencies. Visiting intimate partners were not included in     Interrupted time series and data analysis
the exceptions [7]. The combined effects of the lock-        We analysed STI reported cases between August 1st
down and the unprecedented pressure on health systems        2017 and August 1st 2020 in Catalonia. We have in-
might have reduced the capacity to detect STIs, poten-       cluded three years of follow-up not only in order to esti-
tially leading to increased transmission and more severe     mate the reported cases we would have had from
sequelae, or a decrease in the incidence because of less     lockdown - from March 13th to August 1st, 2020- but
exposure. The objective of this study was to estimate the    also to capture potential seasonal or cyclic changing pat-
magnitude of the decline, due to the COVID-19 pan-           terns. For each of the mentioned variables, among the
demic, in the number of STI reported confirmed cases         STI reported confirmed cases, the total number and its
in Catalonia during the lockdown and de-escalation           distribution in the respective categories were calculated,
phases comparing the observed and expected values.           before lockdown, during lockdown (March 13th to April
                                                             27th), on de-escalation phases (April 28th until June
Methods                                                      21st), and during the new normality phase (since June
The Catalan HIV/STI surveillance systems                     22nd). The main objective of the de-escalation plan was
We used epidemiological data from all STI confirmed          to ensure maintaining the protection of public health
cases reported to the Catalan HIV/STI Registry of Cata-      while gradually recovering the common daily life and
lonia [8] through the Epidemiological Repository of          economic activities after the lockdown. This transition
Catalonia (REC), an electronic database that collects data   to a “new normality” was gradual, asymmetrical, and co-
reported from health care professionals and laboratories     ordinated with the autonomous communities [11]. We
by means of standardized notification forms and epi-         used these dates as change points for an interrupted
demiological questionnaires, both electronically or in       time series (ITS) analysis of daily STI reported cases
paper. According to the mandatory notification of dis-       (overall and separately for each of them). Reported cases
eases and outbreaks Catalan regulation (Health Depart-       were modelled as autoregressive integrated moving aver-
ment of Government of Catalonia article 13 of law 67/        age (ARIMA) processes to estimate expected number of
2010, 25 May 2010), nominal notification of syphilis,        STI reported cases in each specific study period since
gonorrhoea, and LGV cases has been mandatory since           lockdown based on pre-lockdown data. We calculated
2007 and chlamydia since 2015; the notification of HIV       the overall drop in number of STI reported cases, to es-
cases was voluntary between 2001 and 2010 when it also       timate the magnitude of the decline in STI reported
became mandatory and nominal. The European Centre            cases with historical data comparing the observed and
for Disease Prevention and Control (ECDC) guidelines         expected values.
Sentís et al. BMC Public Health       (2021) 21:1637                                                                                             Page 3 of 7

Results                                                                          43.8 STI reported cases/day pre-lockdown to 22.2, 23.4
When comparing with pre-lockdown period’s data, the                              and 27.9 respectively). The proportion of syphilis and
STI reported cases per day decreased by almost 50% in                            LGV slightly increased (from 15% and 1.7% pre-
all three COVID-19 related study periods: during lock-                           lockdown) among the overall STI reported cases in all
down, de-escalation and new normality periods (from                              three COVID-19 related study periods (respectively in

Table 1 Epidemiological characteristics of the STI reported confirmed cases during the different study periodsa in Catalonia, August
1st 2017 to August 1st 2020
                                    Total                  Pre-lockdown             Lockdown            De-escalation Phases             New Normality
Number of reported cases            N = 45,181             N = 41,802               N = 997             N = 1266                         N = 1116
Days,n°reported cases/days          1096         41.2      954          43.8        45        22.2      54               23.4            40           27.9
                                    N            %         N            %           N         %         N                %               N            %
STI
    Chlamydia                       23,095       51.1      21,463       51.3        472       47.3      611              48.3            549          49.1
    Gonorrhoea                      14,406       31.9      13,340       31.9        329       33.0      398              31.4            339          30.3
      LGVb                          815          1.8       723          1.7         28        2.8       29               2.3             35           3.1
    Syphilis                        6865         15.2      6276         15.0        168       16.9      228              18.0            193          17.3
Sex
    Females                         17,860       39.5      16,679       39.9        340       34.1      453              35.8            388          34.7
    Males                           27,321       60.5      25,123       60.1        657       65.9      813              64.2            728          65.2
                     c
Age (mean, SD )                     31.7         11.1      31.7         11.1        31.9      10.6      32.5             11.9            32.3         11.4
Age group
    < 20                            5776         12.8      5384         12.9        113       11.3      154              12.2            125          11.2
    20 to 29                        17,334       38.4      16,052       38.4        376       37.7      477              37.7            429          38.4
    30 to 39                        12,076       26.7      11,180       26.7        282       28.3      321              25.4            293          26.3
    40 to 49                        6702         14.8      6177         14.8        155       15.5      198              15.6            172          15.4
    50 to 59                        2334         5.20      2124         5.1         56        5.6       83               6.6             71           6.4
    ≥ 60                            959          2.1       885          2.1         15        1.5       33               2.6             26           2.3
Deprivation index
    First quintile                  11,221       24.8      10,288       24.6        286       28.70     344              27.20           303          27.2
    Second quintile                 8133         18.0      7436         17.8        214       21.50     240              19.00           243          21.8
    Third quintile                  5329         11.8      4915         11.8        135       13.50     155              12.20           124          11.1
    Fourth quintile                 6150         13.6      5717         13.7        106       10.60     193              15.20           134          12.0
    Fifth quintile                  8246         18.3      7618         18.2        185       18.60     236              18.60           207          18.5
    Missing                         6102         13.5      5828         13.9        71        7.10      98               7.70            105          9.4
Country of birth
    Spain                           13,861       30.7      13,316       31.9        136       13.6      207              16.4            202          18.1
    Others                          4913         10.9      4785         11.4        24        2.4       56               4.4             48           4.3
    Missing                         26,407       58.4      23,701       56.7        837       84.0      1003             79.2            866          77.6
Reinfeccion
    No                              39,619       87.7      36,893       88.3        838       84.1      1019             80.5            869          77.9
    Yes                             5562         12.3      4909         11.7        159       15.9      247              19.5            247          22.1
HIV status
    Negative                        42,809       94.8      39,628       94.8        937       94.0      1196             94.5            1048         93.9
    Positive                        2372         5.2       2174         5.2         60        6.0       70               5.5             68           6.1
a
  Pre-lockdown: from August 1st 2017 to March 12th 2020, lockdown: from March 13th 2020 to April 27th2020, de-escalation phases: from April 28th 2020 to June
21st 2020, new normality: from June 22nd 2020 to August 1st 2020;
b
  LGV: Lymphogranuloma venereum;
c
 SD: Standard deviation
Sentís et al. BMC Public Health      (2021) 21:1637                                                                                              Page 4 of 7

the three study periods to 16.9%, 18%, and 17.3% for                            11.7% to 22.2%, respectively). The proportion of re-
syphilis and 2.8%, 2.3% and 3.1% for LGV) meanwhile                             ported cases in each age groups was similar when com-
gonorrhoea and chlamydia had a small decrease (from                             paring the study periods with previous or historical data
31.9% and 51.3% pre-lockdown to 30.3% and 49.1% in                              (see Table 1).
the “new normality” period for gonorrhoea and for chla-                            In the ITS (see Table 2, Fig. 1, and supplemental ma-
mydia respectively). In addition, the proportion of STI                         terial, figure S1–S4), we observed how the number of all
reported cases from females was reduced when com-                               STI reported cases were only 49% of the expected num-
pared to males (approximately 5% between pre-                                   ber (decrease of − 51%, confidence interval (CI): − 59%
lockdown and new normality periods). STI reported                               to − 38%), based on pre-lockdown data (since August 1st
cases that came from areas with higher socioeconomic                            2020), with variations in the different study periods; be-
status increased by 5% over post-lockdown periods (see                          ing only 44% of the expected reported cases during lock-
Table 1). The proportion of missing data for country of                         down (decrease of − 56%, CI: − 63% to − 46%) and slowly
birth was high during all the different study periods and                       increasing to 55% of the expected since the new normal-
increased by 25% during lockdown (from 56.7% missing                            ity began on June 22nd (decrease of − 45%, CI: − 54% to
values in pre-lockdown data to 84% during lockdown).                            − 30%). When analysing the results by type of infection
The proportion of STI reported cases in people coin-                            we found that chlamydia’s reported cases which repre-
fected by HIV, as well as the proportions of STI reported                       sent more than 50% of all STI reported cases, had the
cases considered as reinfections, increased from pre-                           highest decrease in notification over post-lockdown pe-
lockdown to new normality periods (5.2% to 6.1% and                             riods, with observed reported cases reaching only 28% of

Table 2 Comparing observed and expected number of STI reported confirmed cases during the different study periodsa in
Catalonia, August 1st 2017 to August 1st 2020
                 Periods              observed       expected      upper CIb      lower CIb     difference            upper CIb            lower CIb
All STIs         Pre-lockdown         41,814
                 Lockdown             997            2264          2681           1846          − 1267      −56%      − 1684      −63%     − 849       −46%
                 De-escalation        1266           2546          3078           2015          − 1280      −50%      − 1812      −59%     − 749       −37%
                 New Normality        1116           2026          2446           1606          − 910       −45%      − 1330      −54%     − 490       −30%
                 Total                3379           6836          8205           5467          − 3457      −51%      − 4826      −59%     − 2088      −38%
Chlamydia        Pre-lockdown         21,463
                 Lockdown             472            1607          1731           1483          −1135       −71%      − 1259      −73%     − 1011      −68%
                 De-escalation        611            2376          2535           2216          − 1765      −74%      − 1924      −76%     − 1605      −72%
                 New Normality        549            1870          1997           1743          − 1321      −71%      − 1448      −73%     − 1194      −68%
                 Total                1632           5853          6264           5442          − 4221      −72%      − 4632      −74%     − 3810      −70%
Gonorrhoea       Pre-lockdown         13,340
                 Lockdown             329            747           889            605           −418        −56%      −560        −63%     −276        −46%
                 De-escalation        398            857           1037           678           − 459       −54%      − 639       −62%     −280        −41%
                 New Normality        339            670           812            529           − 331       −49%      − 473       − 58%    −190        −36%
                 Total                1066           2275          2738           1812          − 1209      −53%      − 1672      −61%     − 746       − 41%
Syphilis         Pre-lockdown         6276
                 Lockdown             168            250           337            164           −82         −33%      − 169       −50%     4           2%
                 De-escalation        228            284           392            177           −56         −20%      − 164       −42%     51          29%
                 New Normality        193            218           302            134           −25         −11%      −109        −36%     59          44%
                 Total                589            753           1030           475           −164        −22%      − 441       −43%     114         24%
    c
LGV              Pre-lockdown         723
                 Lockdown             28             54            62             47            −26         −48%      −34         −55%     −19         −40%
                 De-escalation        29             80            89             71            −51         −64%      −60         −67%     −42         −59%
                 New Normality        35             56            63             49            −21         −38%      −28         −45%     −14         −29%
                 Total                92             191           214            167           −99         −52%      − 122       −57%     −75         −45%
a
 Pre-lockdown: from August 1st 2017 to March 12th 2020, lockdown: from March 13th 2020 to April 27th2020, de-escalation phases: from April 28th 2020 to June
21st 2020, new normality: from June 22nd 2020 to August 1st 2020; bCI, confidence interval; cLGV, lymphogranuloma venereum
Sentís et al. BMC Public Health   (2021) 21:1637                                                                                    Page 5 of 7

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                                                                        Date

 Fig. 1 Observed and expected time series trends of daily STI reported confirmed cases in Catalonia during the COVID-19 pandemic, August 1st
 2017 - August 1st 2020 (dark grey: lockdown, light grey: de-escalation phases)

the expected values. Conversely, we observed that the                     previous STI episodes in the last three years, or HIV
decrease of syphilis reported cases was lower, with ob-                   positive are more likely to seek health care.
served reported cases reaching 78% of those expected                        To the best of our knowledge, few analysis have de-
(see Table 2 and supplemental material, figure S1 and                     scribed the estimated magnitude and impact of the
figure S3).                                                               COVID-19 pandemic on the expected number of STIs
                                                                          compared to the most recent historical data. Although
Discussion                                                                few articles have analysed STI incidences during lock-
We found that since the start of COVID-19 pandemic                        down, some authors argue that the plausible decrease of
the number of STI reported cases was 51% less than ex-                    sexually relations during the COVID-19 pandemic may
pected, reaching an average of 56% during lockdown (50                    partially explain the apparent drop in the number of STI
and 45% during de-escalation and new normality) with a                    incidence [12–14]. In spite of these, different stake-
maximum decrease of 72% for chlamydia and minimum                         holders have started raising awareness about disruptions
of 22% for syphilis. Our results indicate that STIs were                  in sexual health services including STI and HIV testing
less reported in females, people living in more deprived                  and detection [15, 16]. Moreover, it has been estimated
areas, people with no previous STI episodes during the                    that in the Atlanta (State of Georgia, United States), if
last three years, and without HIV infection.                              sexual behaviour rebounds while service interruption
  We hypothesize that the decline in the number of STI                    persists, cases will increase in hundreds for HIV and in
reported cases was higher in females based on the an-                     thousands for STIs for the next five years [17]. Berzkalns
nual STI notification rates in the region where chla-                     et al. performed a study in King County (State of Wash-
mydia has been usually higher among females and                           ington, United States) where the number of sexual
syphilis among males [1]. STIs, including chlamydia in-                   health clinic visits decreased 55% during lockdown. Al-
fection are predominantly asymptomatic in females, and                    though after lockdown numbers returned to pre-
are detected primarily through screening. During lock-                    lockdown values, around lockdown, from January–July
down, mobility restrictions may have decreased health-                    2020, the number of STIs diagnosed declined differently
care seeking behaviour in asymptomatic individuals with                   depending on the STI, from 9% for gonorrhoea to 22%
high-risk exposures. This decrease could be even greater                  for early latent syphilis [18]. They suggested that a real
for people living in more deprived areas. Additionally,                   decline may have happened, but the larger decline in
people who already visited sexual health care for                         asymptomatic STIs probably indicates decreased
Sentís et al. BMC Public Health        (2021) 21:1637                                                                                              Page 6 of 7

screening. Similarly, Chow et al. described that, al-                           Supplementary Information
though a relevant decrease in the total number of                               The online version contains supplementary material available at https://doi.
                                                                                org/10.1186/s12889-021-11630-x.
consultations occurred in the Melbourne Sexual
Health Centre during the lockdown, for more severe                               Additional file 1: Fig. S1. Expected and observed time series trends of
conditions such as pelvic inflammatory disease or in-                            daily Chlamydia reported confirmed cases in Catalonia, August 1st 2017 -
fectious syphilis, a similar number of consultations to                          August 1st 2020 (dark grey: lockdown, light grey: de-escalation phases).
                                                                                 Fig. S2. Expected and observed time series trends of daily Gonorrhoea
the pre-lockdown period was observed [19]. Recently,                             reported confirmed cases in Catalonia, August 1st 2017 - August 1st 2020
an article from the EuroTEST COVID-19 impact as-                                 (dark grey: lockdown, light grey: de-escalation phases). Fig. S3. Expected
sessment consortium described that, among 34 coun-                               and observed time series trends of daily Syphilis reported confirmed
                                                                                 cases in Catalonia, August 1st 2017 - August 1st 2020 (dark grey: lock-
tries in the World Health Organization (WHO)                                     down, light grey: de-escalation phases). Fig. S4. Expected and observed
European Region and in different testing settings, 95%                           time series trends of daily lymphogranuloma venerum (LGV) reported
of them declared to have tested less than half the ex-                           cases in Catalonia, August 1st 2017 - August 1st 2020 (dark grey: lock-
                                                                                 down, light grey: de-escalation phases).
pected number of people between March and May
2020, a decline that continued at lesser degrees until
August 2020 [20]. Then, this decline probably is due                            Acknowledgements
to the effect of a combination of factors; changes in                           We thank all the reporting physicians and people working in HIV/STI
the people’s behaviour, sexual relationships or fear of                         surveillance in Catalonia who have contributed in the collection and quality
                                                                                of the information in the surveys including the Catalan HIV and STI
visiting a health care setting [21], less available re-                         Surveillance Group, which is composed by the following members: A Sentís,
sources to diagnose and notify STIs (including human                            E López, V Gonzalez, R Lugo, MP Bonamusa, J Reyes, J Casabona (Centre
resources), and surveillance systems which were not                             d’Estudis Epidemiològics sobre les Infeccions de Transmissió Sexual i Sida de
                                                                                Catalunya); P Garcia de Olalla, Lilas Mercuriali, R Clos, R Rodriguez, M Masdeu,
able to integrate the immediate reaction to a pan-                              M Ros, P Simon, I Avellaneda, A Artigas,C Rius (Servei d’Epidemiologia de
demic, while coping with their regular surveillance                             l’Agència de Salut Pública de Barcelona); M Company, M Danés, N Camps
activities.                                                                     (Servei de Vigilància Epidemiològica i Resposta a Emergències de Salut
                                                                                Pública a Girona); RM Vileu, G Ferrús, N Borrell, S Minguell (Servei de
                                                                                Vigilància Epidemiològica i Resposta a Emergències de Salut Pública a
                                                                                Tarragona); J Ferràs (Servei de Vigilància Epidemiològica i Resposta a
Conclusions                                                                     Emergències de Salut Pública a Terres de l’Ebre); I Parrón (Servei de Vigilància
Our results showed that the STI notification sharp de-                          Epidemiològica i Resposta a Emergències de Salut Pública al Barcelonès
                                                                                Nord i Maresme); I Mòdol, A Martinez, P Godoy (Servei de Vigilància
cline was maintained almost five months since lock-                             Epidemiològica i Resposta a Emergències de Salut Pública a Lleida); MA
down, well into the new normality. This can hardly be                           Tarrès, J Pérez, M Boldú, I Barrabeig (Servei de Vigilància Epidemiològica i
explained without significant underdiagnoses and under-                         Resposta a Emergències de Salut Pública a Barcelona Sud); E Donate, L
                                                                                Clotet, MR Sala (Servei de Vigilància Epidemiològica i Resposta a
reporting. The gradual increase in the number of STI re-                        Emergències de Salut Pública al Vallès Occidental i Vallès Oriental); M Carol, V
ported cases that we observed after lockdown may be                             Guadalupe-Fernández (Servei de Vigilància Epidemiològica i Resposta a Emer-
pointing out the possibility that lockdowns did not com-                        gències de Salut Pública a Catalunya Central) and J Mendioroz, P Ciruela, G
                                                                                Carmona, R Mansilla, JL Martínez, S Hernández (Subdirecció General de Vigi-
pletely disrupt STI transmission. As discussed in the                           lància Epidemiològica i Resposta a Emergències de Salut Pública, Agència de
present article, with the available current scientific evi-                     Salut Pública de Catalunya).
dence, it seems that the observed decrease in the num-
ber of STI reported cases during the current COVID-19                           Authors’ contributions
pandemic is probably due to a combination of factors.                           AS and JC conceptualized the paper. AS and APU designed the study. MMF
More research is needed in order to disentangle the spe-                        cleaned the database. AS and APU reviewed scientific literature, performed
                                                                                the statistical analysis, and drafted the manuscript. AS, APU, JC, JRU, ELC, DN,
cific role and relevance that has had underdiagnosis,                           PG, LM, NB, VGF, and Catalan HIV and STI Surveillance Group interpreted the
underreporting, and the decrease in sexual risk activities                      results and contributed to improving the content in the sections of their
and other potential factors in this decline. Finally, we                        expertise. The Catalan HIV and STI Surveillance Group managed and verified
                                                                                all the reported cases. All the authors collaborated in the critical review and
truly believe that there is an urgent need to strengthen                        approved the final manuscript.
STI/HIV diagnostic programs and services, as well as
surveillance, as the pandemic could be concealing the
                                                                                Funding
real size of the already described re-emergence of STIs                         AP-U is supported by Fundacion Alfonso Martin Escudero and the Medical
[22].                                                                           Research Council (grant numbers MR/K501256/1, MR/N013468/1).

Abbreviations                                                                   Availability of data and materials
COVID-19: The coronavirus disease 2019; STI: Sexually transmitted infections;   Public access to the database(s) is close. Data sharing is not possible because
LGV: Lymphogranuloma venereum; MSM: Males who have sex with males;              patients’ individual privacy could be compromised. Although data was de-
HIV: Human immunodeficiency virus; REC: Epidemiological repository of           identified to be handled, some aggregated results could be sensitive when
Catalonia; XVEC: The Epidemiological Surveillance Network of Catalonia;         communicated at a population level. For this reason, the analysis and dis-
ECDC: European Centre for Disease Prevention and Control; ITS: Interrupted      semination of this data is handled by public health authorities with surveil-
time series; ARIMA: Autoregressive integrated moving average;                   lance responsibilities and avoiding disaggregation by small geographical
CI: Confidence interval; WHO: World Health Organization                         areas.
Sentís et al. BMC Public Health         (2021) 21:1637                                                                                                     Page 7 of 7

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Ethics approval by an ethics committee was not necessary according to                      socioeconòmic per al finançament de les ABS. Observatori del Sistema de
national regulations; Data from mandatory notifiable disease in REC                        Salut de Catalunya. 2017. http://observatorisalut.gencat.cat/ca/observatori-
application were handled according to Spanish Organic Law 3/2018 on Data                   desigualtats-salut/indicador_socioeconomic_2015/. Accessed 6 Aug 2020.
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Patients were not directly involved in this study; only data coming from             11.   Plan para la transición hacia una nueva normalidad. 28 de abril 2020.
notifiable disease surveillance systems were used which did not imply any                  Gobierno de España. Ministerio de Sanidad. https://www.lamoncloa.gob.es/
additional approval requirements. Data was handled anonymously by                          consejodeministros/resumenes/Documents/2020/PlanTransicionNueva
researchers from the Centre of epidemiological studies on sexually                         Normalidad.pdf. Accessed 25 May 2021.
transmitted infections and AIDS of Catalonia (CEEISCAT) (Department of               12.   Mohamed A, Hammoud LM, et al. Physical distancing due to COVID-19
Health, Generalitat of Catalonia, Spain), which has the mandate of collect,                disrupts sexual behaviours among gay and bisexual men in Australia. JAIDS
analyse and disseminate STI/HIV surveillance data in Catalonia, as part of                 J Acquir Immune Defic Syndr. https://pubmed.ncbi.nlm.nih.gov/32740374/.
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                                                                                           infection on sexual health. AIDS Behav. 2020;1(8):1–2259. https://doi.org/10.1
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Consent for publication
                                                                                     14.   Balestri R, Magnano M, Rizzoli L, Infusino SD, Urbani F, Rech G. STIs and the
Not applicable.
                                                                                           COVID-19 pandemic: the lockdown does not stop sexual infections. J Eur
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Competing interests                                                                  15.   Tang K, Gaoshan J, Ahonsi B. Sexual and reproductive health (SRH): a key
The authors declare that they have no competing interests.                                 issue in the emergency response to the coronavirus disease (COVID-19)
                                                                                           outbreak. Reprod Health. 2020;17(1):59. https://doi.org/10.1186/s12978-020-
Author details                                                                             0900-9.
1                                                                                    16.   Sanchez TH, Zlotorzynska M, Rai M, Baral SD. Characterizing the impact of
 Centre of epidemiological studies on sexually transmitted infections and
AIDS of Catalonia (CEEISCAT). Department of Health. Generalitat of Catalonia,              COVID-19 on men who have sex with men across the United States in April,
Badalona, Spain. 2Spanish Consortium for Research on Epidemiology and                      2020. AIDS Behav. 2020;24(7):2024–32. https://doi.org/10.1007/s10461-020-02
Public Health (CIBERESP), Instituto de Salud Carlos III, Madrid, Spain. 3Pompeu            894-2.
Fabra University (UPF), Barcelona, Spain. 4Epiconcept, Epidemiology                  17.   Jenness SM, Le Guillou A, Chandra C, Mann LM, Sanchez T, Westreich D,
Department, Paris, France. 5Centre for Statistics in Medicine, Botnar Research             et al. Projected HIV and bacterial STI incidence following COVID-related
Centre, NDORMS, University of Oxford, Oxford, UK. 6Department of                           sexual distancing and clinical service interruption. medRxiv. 2020. https://
Paediatrics, Obstetrics and Gynecology and Preventive Medicine, Universitat                doi.org/10.1101/2020.09.30.20204529.
Autónoma de Barcelona, Badalona, Spain. 7Epidemiological Service of Public           18.   Berzkalns A, Thibault CS, Barbee LA, Golden MR, Khosropour C, Kerani RP.
Health Agency of Barcelona, Barcelona, Spain. 8Epidemiological Surveillance                Decreases in reported sexually transmitted infections during the time of
and Response to Public Health Emergencies Service in Tarragona Camp,                       COVID-19 in King County, WA: decreased transmission or screening? Sex
Agency of Public Health of Catalonia, Generalitat of Catalonia, Tarragona,                 Transm Dis. 2021;48(8S):S44–9. https://doi.org/10.1097/OLQ.00000000000014
Spain. 9Epidemiological Surveillance and Response to Public Health                         63.
Emergencies Service in Central Catalonia, Agency of Public Health of                 19.   Chow EPF, Hocking JS, Ong JJ, Phillips TR, Fairley CK. Sexually transmitted
Catalonia, Generalitat of Catalonia, Manresa, Spain.                                       infection diagnoses and access to a sexual health service before and after
                                                                                           the National Lockdown for COVID-19 in Melbourne, Australia. Open Forum
Received: 17 October 2020 Accepted: 13 August 2021                                         Infect Dis. 2021;8(1). https://doi.org/10.1093/ofid/ofaa536.
                                                                                     20.   Simões D, Stengaard AR, Combs L, Raben D. Impact of the COVID-19
                                                                                           pandemic on testing services for HIV, viral hepatitis and sexually transmitted
                                                                                           infections in the WHO european region, march to august 2020.
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